In vitro fertilization (IVF)

Definition

In vitro fertilization (IVF) is the joining of a woman?s egg and a man?s sperm in a laboratory dish. In vitro means ?outside the body.? Fertilization means the sperm has attached to and entered the egg.

See also:

• Infertility
• Infertility resources

Alternative Names

IVF; Assisted reproductive technology; ART; Test-tube baby procedure

Description

Normally, an egg and sperm are fertilized inside a woman?s body. If the fertilized egg attaches to the lining of the womb and continues to grow, a baby is born about 9 months later. This process is called natural or unassisted conception.

IVF is a form of assisted reproductive technology (ART). This means special medical techniques are used to help a woman become pregnant. IVF has been successfully used since 1978. It is most often tried when other, less expensive fertility techniques have failed.

There are five basic steps to IVF:

Step 1: Stimulation, also called super ovulation

Medicines, commonly called fertility drugs, are given to the woman to boost her egg production. Normally, a woman produces one egg per month. Fertility drugs tell the ovaries to produce several eggs. During this step, the woman will have regular transvaginal ultrasounds to examine the ovaries and blood tests to check hormone levels.

Step 2: Egg retrieval

A minor surgery, called follicular aspiration, is done to remove the eggs from the woman?s body. The surgery is normally done as an outpatient procedure in the doctor?s office. The woman will be given medicines so she does not feel pain during the procedure. Using ultrasound images as a guide, the health care provider inserts a thin needle through the vagina and into the ovary and sacs (follicles) containing the eggs. The needle is connected to a suction device, which pulls the eggs and fluid out of each follicle, one at a time. The procedure is repeated for the other ovary. The woman may have some cramping after the surgery, but it usually goes away within a day. In rare cases, a pelvic laparoscopy may be needed to remove the eggs.

If a woman does not or cannot produce any eggs, donated eggs may be used.

Step 3: Insemination and Fertilization

The man?s sperm is placed together with the best quality eggs and stored in an environmentally controlled chamber. The mixing of the sperm and egg is called insemination. The sperm usually enters (fertilizes) an egg a few hours after insemination. If the doctor thinks the chance of fertilization is low, the laboratory staff may directly inject the sperm into the egg. This is called intracytoplasmic sperm injection (ICSI). Many fertility programs routinely do ICSI on some of the eggs even if everything is normal.

Step 4: Embryo culture

When the fertilized egg divides, it becomes an embryo. Laboratory staff will regularly check the embryo to make sure it is growing properly. Within about 5 days, a normal embryo has several cells that are actively dividing.

Couples who have a high risk of passing a genetic (hereditary) disorder to a child may consider pre-implantation genetic diagnosis (PGD). The procedure is done about 3 -4 days after fertilization. Laboratory scientists remove a single cell from each embryo and screen the material for specific genetic disorders. According to the American Society for Reproductive Medicine, PGD can help parents decide which embryos to implant, which decreases the chance of passing a disorder onto a child. The technique is controversial and not offered at all centers.

Step 5: Embryo transfer

Embryos are placed into the woman?s womb 3 - 5 days after egg retrieval and fertilization. The procedure is done in the doctor?s office while the woman is awake. The doctor inserts a thin tube (catheter) containing the embryos into the woman?s vagina, through the cervix, and up into the womb. If an embryo sticks to (implants) in the lining of the womb and grows, pregnancy results.

More than one embryo may be placed into the womb at the same time, which can lead to twins, triplets, or more. The exact number of embryos transferred is a complex issue that depends on many factors, especially the woman?s age. Unused embryos may be frozen and implanted or donated at a later date.

Why the Procedure Is Performed

IVF is done to help a woman become pregnant. It is used to treat many causes of infertility, including:

• Advanced age of the woman (advanced maternal age)
• Damaged or blocked fallopian tubes (can be caused by pelvic inflammatory disease or prior reproductive surgery)
• Endometriosis
• Male factor infertility, including decreased sperm count and blockage
• Unexplained infertility

Risks

IVF requires a significant physical, emotional, financial, and time commitment. Stress and depression are common among couples dealing with infertility. A woman taking fertility medicines may have bloating, abdominal pain, mood swings, headaches, and other side effects. Many IVF medicines must be given by injection, often several times a day. (The health care team will teach the couple how to properly mix the medicines and give a shot.) Repeated injections can cause bruising.

In rare cases, fertility drugs may cause ovarian hyperstimulation syndrome (OHSS). This condition causes a build up of fluid in the abdomen and chest. Symptoms include abdominal pain, bloating, rapid weight gain (10 pounds within 3-5 days), decreased urination despite drinking plenty of fluids, nausea, vomiting, and shortness of breath. Mild cases can be treated with bed rest. More severe cases require draining of the fluid with a needle.

Medical studies to date have concluded that fertility drugs are not linked to ovarian cancer.

Risks of egg retrieval include reactions to anesthesia, bleeding, infection, and damage to structures surrounding the ovaries, including the bowel and bladder.

There is a risk of multiple pregnancies when more than one embryo is placed into the womb. Carrying more than one baby at a time increases the risk of premature birth and low birth weight. (However, even a single baby born after IVF is at higher risk for prematurity and low birth weight.) It is unclear whether IVF increases the risk of birth defects.

IVF is very costly. Some, but not all, states have laws that say health insurance companies must offer some type of coverage. But, many insurance plans do not cover infertility treatment. Fees for a single IVF cycle -- including costs for medicines, surgery, anesthesia, ultrasounds, blood tests, processing the eggs and sperm, embryo storage, and embryo transfer -- can quickly add up. The exact total of a single IVF cycle varies with each individual, but may cost more than $12,000 - $17,000.

Before the Procedure

After the Procedure

Statistics vary from one clinic to another and must be carefully interpreted.

• Pregnancy rates reflect the number of women who became pregnant after IVF. But not all pregnancies result in a live birth.
• Live birth rates reflect the number of women who give birth to a living child.

According to the Society of Assisted Reproductive Technologies (SART), the approximate chance of giving birth to a live baby after IVF is as follows:

• 41-43% for women under age 35
• 33-36% for women age 35 - 37
• 23-27% for women ages 38 - 40
• 13-18% for women over age 41

Outlook (Prognosis)

After embryo transfer, the woman may be told to rest for the remainder of the day. Complete bed rest is not necessary, unless there is an increased risk of OHSS. Most women return to normal activities the next day.

Women who undergo IVF must take daily shots or pills of the hormone progesterone for 8 - 10 weeks after the embryo transfer. Progesterone is a hormone produced naturally by the ovaries that helps thicken the lining of the womb (uterus). This makes it easier for the embryo to implant. Too little progesterone during the early weeks of pregnancy may result in a miscarriage.

About 12 -14 days after the embryo transfer, the woman will return to the clinic so that a pregnancy test can be done. (See: hCG quantitative test)

Call your health care provider right away if you had IVF and have:

• A fever over 100.5 F (38 C)
• Pelvic pain
• Heavy bleeding from the vagina
• Blood in the urine

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References

Lobo RA. Infertility: etiology, diagnostic evaluation, management, prognosis. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007:chap 41.

Min JK. Guidelines for the number of embryos to transfer following in vitro fertilization. J Obstet Gynaecol Can. Sept 2006; 28(9): 799-813.

The Practice Committee of the Society for Assisted Reproductive Technology and the Practice Committee of the American Society for Reproductive Medicine. Guidelines on number of embryos transferred. Fertil Steril. 2006 Nov;86 Suppl 5:S51-2.

Jackson RA, Gibson KA, Wu YW, et al. Perinatal Outcomes in Singletons following in vitro fertilization: a meta-analysis. Obstet Gynecol. 2004; 103: 551- 563

Society for Assisted Reproductive Technologists. Clinic Summary Report: All SART Member Clinics. 2005.